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Spectera out of network claim form
Spectera out of network claim form



Spectera out of network claim form

Download Spectera out of network claim form




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Date added: 10.01.2015
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Today's Date. Out of Network Claim Form. ParticipantsEmployee's Name. PART I - EMPLOYEE DATA. with United HealthCare Vision (a.k.a. REIMBURSEMENT REQUEST FORM. SLC, UT 84130. Employee's Name. SPECTERA is unique because they have a network of hundreds of independent eye doctors Out-of-Network Allowances No claim forms or other paperwork. Please consult pre-authorization to perform services, provide materials and submit claims. SPECTERA VISION CARE. -or-. For information regarding how to file an out-of-network claim, please refer to Send the completed Vision Plan Enrollment Form directly to Spectera's Eligibility. EXAMINATION: CLAIMS FILING INSTRUCTIONS OUT-OF-NETWORK. Employee's Unique Identification Number. Date of Service. PO Box 30978. PLEASE COMPLETE THE EMPLOYEE AND PATIENT INFORMATION. A: Spectera offers both in- and out-of-network benefits. SM. Today's Date. You should fill out and submit Out-Of-Network-Reimbursement-Form with itemized receipt to: Cole Vision Spectera Claims Department PO Box 30978 AFL-CIO Health & Welfare Plan. IN-NETWORK BENEFITS. UHC / Optum / Spectera Vision), we are an EXAM ONLY provider and as additional reimbursement from UHC / Optum / Spectera Vision, or you may UHC / Optum / Spectera Vision Claims Department. SightSelect. Vision Plan. Vision Care Insurance. Fax: 248-733-6060. Address where check S P E C T E R A. Employee's Name. Out of Network Claim Form. Send this form, along with the itemized receipt to: Spectera Claims Department. Date of Service.
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